Management of lumbar bone stress injury in cricket fast bowlers and other athletes

Background

Recent guidelines (including a special series in The Lancet) have emphasised a minimal role for imaging when assessing low back pain in adults, as the majority of patients will have non-specific findings on imaging that do not correlate well with pain.

Objective

To assess whether the diagnosis of lumbar bone stress injuries in young athletes should be considered an exception to the recommendation to avoid imaging for low back pain in adults.

Method

Narrative review.

Results

Early lumbar bone stress injury diagnosis has been available via traditional MRI sequences (and its precursor Single Photon Emission Computed Tomography (SPECT)) for 25-30 years. MRI assessments using bone window sequences (such as Volumetric Interpolated Breath-hold Examination (VIBE)) have allowed a better understanding of the diagnosis and prognosis of lumbar bone stress injury in young athletes. MRI with bone sequences has allowed non-radiating scans to serially follow the healing of unilateral stress fractures. In the majority of cases, non-chronic unilateral fractures can heal; however, this takes three-six months rather than the six-ten weeks that would be the typical unloading period if using symptoms (only) as a guide. The use of MRI to provide evidence of bony healing (as opposed to fibrous union, which creates the pars defect that predisposes to further bone stress lesions) can lead to better long-term outcomes in athletes. There is evidence to flag this as a structural lesion which is both painful and, more importantly, can heal/resolve if managed correctly. Therefore it represents an important 'specific' diagnostic subset within adult low back pain.

Conclusion

Structural (rather than functional) management of bone stress injuries in high-demand athletes, such as cricket pace bowlers, is in contrast to the recommendation of functional management for general back pain in adults. Structural management is justified when there are demonstrable superior outcomes of having better structure. Although this has not yet been shown in randomised trials of elite athletes, apparent lengthier Test cricket careers of pace bowlers who do not have pars defects suggest better athletic outcomes if bony healing is achieved. For lower demand young adults, or athletes with established bilateral pars defects, functional management may be more pragmatic.

Massively parallel base editing to map variant effects in human hematopoiesis

Systematic evaluation of the impact of genetic variants is critical for the study and treatment of human physiology and disease. While specific mutations can be introduced by genome engineering, we still lack scalable approaches that are applicable to the important setting of primary cells, such as blood and immune cells. Here, we describe the development of massively parallel base-editing screens in human hematopoietic stem and progenitor cells. Such approaches enable functional screens for variant effects across any hematopoietic differentiation state. Moreover, they allow for rich phenotyping through single-cell RNA sequencing readouts and separately for characterization of editing outcomes through pooled single-cell genotyping. We efficiently design improved leukemia immunotherapy approaches, comprehensively identify non-coding variants modulating fetal hemoglobin expression, define mechanisms regulating hematopoietic differentiation, and probe the pathogenicity of uncharacterized disease-associated variants. These strategies will advance effective and high-throughput variant-to-function mapping in human hematopoiesis to identify the causes of diverse diseases.

Safety and efficacy of voxelotor in pediatric patients with sickle cell disease aged 4 to 11 years

BACKGROUND

Sickle cell disease (SCD) is a devastating, multisystemic disorder that affects millions of people worldwide. The earliest clinical manifestations of SCD can affect infants as young as 6 months of age, and pediatric patients are at risk for acute and life-threatening complications. Early intervention with treatments that target the underlying pathophysiological mechanism of SCD, sickle hemoglobin (HbS) polymerization, are expected to slow disease progression and circumvent disease-associated morbidity and mortality.

PROCEDURE

The HOPE-KIDS 1 trial (NCT02850406) is an ongoing four-part, phase 2a, open-label, single- and multiple-dose study to evaluate the pharmacokinetics, efficacy, and safety of voxelotor-a first-in-class HbS polymerization inhibitor-in patients aged 6 months to 17 years with SCD. Initial findings from a cohort of 45 patients aged 4 to 11 years who received voxelotor treatment for up to 48 weeks are reported.

RESULTS

Hemoglobin (Hb) response, defined as a >1.0 g/dl increase from baseline, was achieved at week 24 by 47% (n = 16/34) of patients with Hb measurements at baseline and week 24. At week 24, 35% (n = 12/34) and 21% (n = 7/34) of patients had a >1.5 g/dl increase and a >2.0 g/dl increase from baseline in Hb concentration, respectively. Concurrent improvements in hemolytic markers were observed. Voxelotor was well tolerated in this young cohort, with no newly emerging safety signals.

CONCLUSIONS

Based on its mechanism as an HbS polymerization inhibitor, voxelotor improves Hb levels and markers of hemolysis and has the potential to mitigate SCD-related complications; these results support its use in patients aged ≥4 years.

Peripartum management of a parturient with type 1C (clearance) von Willebrand disease

Peripartum replacement of factor VIII and von Willebrand factor is not usually required in type 1 von Willebrand disease, as the levels of endogenous factors tend to increase to within the normal range as a physiological change of pregnancy. However, there is wide heterogeneity of genotypes and phenotypes associated with type 1 von Willebrand disease. Here, we describe the anesthetic management of a parturient with type 1C von Willebrand disease, a subtype characterized by decreased plasma von Willebrand factor survival.

Surveying managers to inform a regionally relevant invasive Phragmites australis control research program

Managers of invasive species consider the peer-reviewed literature only moderately helpful for guiding their management programs. Though this "knowing-doing gap" has been well-described, there have been few efforts to guide scientists in how to develop useful and usable science. Here we demonstrate how a comprehensive survey of managers (representing 42 wetland management units across the Great Salt Lake watershed) can highlight management practices and challenges (here for the widespread invasive plant, Phragmites australis, a recent and aggressive invader in this region) to ultimately inform a research program. The diversity of surveyed organizations had wide-ranging amounts of Phragmites which led to different goals and approaches including more aggressive control targets and a wider array of control tools for smaller, private organizations compared to larger government-run properties. We found that nearly all managers (97%) used herbicide as their primary Phragmites control tool, while burning (65%), livestock grazing (49%), and mowing (43%) were also frequently used. Managers expressed uncertainties regarding the timing of herbicide application and type of herbicide for effective control. Trade-offs between different Phragmites treatments were driven by budgetary concerns, as well as environmental conditions like water levels and social constraints like permitting issues. Managers had specific ideas about the plant communities they desired following Phragmites control, yet revegetation of native species was rarely attempted. The results of this survey informed the development of large-scale, multi-year Phragmites control and native plant revegetation experiments to address management uncertainties regarding herbicide type and timing. The survey also facilitated initial scientist-manager communication, which led to collaborations and knowledge co-production between managers and researchers. An important outcome of the survey was that experimental results were more pertinent to manager needs and trusted by managers. Such an approach that integrates manager surveys to inform management experiments could be adapted to any developing research program seeking to be relevant to management audiences.

Is hip range of motion and strength impaired in people with hip chondrolabral pathology?

OBJECTIVE

The aims of this study were to: i) to compare physical impairments in people with chondrolabral pathology identified at hip arthroscopy 12-24 months previously to age-matched healthy people; and ii) to understand whether sex has any influence on impairments.

METHODS

84 patients (42 female; age=36±10) 12-24 months post hip arthroscopy and 60 controls (41 female; age=36±10) were included. Measurements of active hip ROM and strength were assessed. Two-way analyses of co-variance examined the effect of sex and chondrolabral pathology on hip ROM and strength.

RESULTS

Patients exhibited less hip internal rotation (IR) ROM (p=0.001) and more extension (p=0.014) ROM; and less hip adduction (p<0.001), extension (p=0.001), flexion (p<0.001), ER (p=0.044) and IR (p<0.001) strength when compared to controls. For abduction strength, a significant interaction was found between the presence of chondrolabral pathology and sex (p=0.035).

CONCLUSIONS

People with hip chondrolabral pathology have differences in hip ROM and strength when compared to controls. Rehabilitation programs should focus on addressing these specific physical impairments in order to enhance outcomes. This information may be of great value to both researchers and clinicians alike in determining interventions to improve outcomes in people with early hip OA.

Assessing child care providers' knowledge and attitudes regarding support of breastfeeding in a region with low breastfeeding prevalence

BACKGROUND

Working mothers who place their infants into out-of-home child care face many challenges to sustaining breastfeeding. Child care providers, who are in frequent close contact with young families, may be potential resources for promoting breastfeeding.

OBJECTIVES

This study focused on identifying child care providers' attitudes toward and knowledge about breastfeeding as well as providers' perceptions about strategies to increase breastfeeding rates among mothers of infants in child care centers.

METHODS

Seventy-five providers from 11 child care centers in the Baton Rouge, Louisiana, area were surveyed using paper and pencil questionnaires. Self-reported demographics, attitudes, knowledge, and perceptions about breastfeeding were collected.

RESULTS

Responses demonstrated a generally positive attitude toward breastfeeding among child care providers but a knowledge deficit in terms of the health impacts and proper handling of breast milk. A minority of providers reported that their center's staff currently receives breastfeeding education, but most providers believed that measures to promote the use of breast milk in their center should target parents rather than the center staff.

CONCLUSION

Child care providers need resources about the benefits of human milk, proper handling of expressed milk, and ways to make centers more breastfeeding friendly. Many providers feel ineffective in supporting breastfeeding and are unaware of the role they may play in mothers' infant feeding decisions. Though child care providers do not appear to believe they can influence parents' decisions about breastfeeding, educating and empowering them could play an important role in increasing breastfeeding rates.

CLN5 mutations are frequent in juvenile and late-onset non-Finnish patients with NCL

OBJECTIVES

To explore a potential expansion of the phenotypic and genotypic characteristics of Finnish variant late-infantile neuronal ceroid lipofuscinosis (NCL), we screened a collection of 47 patients with clinically diagnosed NCL in whom no molecular diagnosis had been made.

METHODS

We used PCR amplification of genomic DNA, followed by fluorescent-labeled dideoxy-nucleotide chain termination sequencing and multiplex ligation-dependent probe amplification, to screen our cohort of patients for mutations in CLN5. We collected ethnic background, clinical, and pathologic information, as available, to clarify the breadth of CLN5 disease expression and to explore possible genotype-phenotype correlations.

RESULTS

We identified 10 patients with pathogenic CLN5 mutations, including 11 mutations not previously described: 4 missense, 5 out-of-frame insertion/deletion mutations, and 2 large intragenic deletions. We also documented 3 previously reported CLN5 mutations. The age at disease onset in this cohort is predominantly juvenile rather than late infantile. Importantly, we have identified 2 adult-onset patients who share a common pathogenic allele. The majority of patients presented with motor and visual impairments and not seizures. In those patients with available longitudinal data, most had progressed to global neurodevelopmental and visual failure with seizures within 1 to 4 years.

CONCLUSIONS

Our study suggests that CLN5 mutations 1) are more common in patients with neuronal ceroid lipofuscinosis (NCL) than previously reported, 2) are found in non-Finnish NCL patients of broad ethnic diversity, and 3) can be identified in NCL patients with disease onset in adult and juvenile epochs. CLN5 genetic testing is warranted in a wider population with clinical and pathologic features suggestive of an NCL disorder.

Imiglucerase (Cerezyme) improves quality of life in patients with skeletal manifestations of Gaucher disease

Health-related quality of life (HRQOL) can be diminished in patients with type 1 Gaucher disease (GD) owing to the debilitating clinical manifestations of this chronic disease. This study investigates the impact of imiglucerase treatment on HRQOL of patients with type 1 GD and bone involvement. Thirty-two previously untreated type 1 GD patients with skeletal manifestations including bone pain, medullary infarctions, avascular necrosis, and lytic lesions received biweekly imiglucerase (at 60 U/kg). The Short Form-36 Health Survey (SF-36) was administered at regular intervals to assess HRQOL. Mean baseline SF-36 physical component summary (PCS) scores were diminished relative to US general population norms. Low PCS scores were more common in patients with medullary infarction, lytic lesions, and higher bone pain severity scores. Statistically significant improvements were observed for all eight SF-36 subscales after 2 years of treatment. Mean PCS and mental component summary (MCS) scores increased to within the normal range after 2 years of treatment and were maintained through year 4. Large HRQOL gains were observed even in patients with the most advanced disease and lowest baseline PCS scores. Imiglucerase treatment has a significant positive impact on HRQOL of type 1 GD patients with skeletal disease, including those with bone infarctions, lytic lesions, and avascular necrosis.

Comparison of the nicotine content of tobacco used in bidis and conventional cigarettes

OBJECTIVE

To compare the nicotine content of 12 unfiltered brands of bidi cigarettes (hand rolled cigarettes imported from India) with 8 popular brands of filtered and unfiltered US and conventional cigarettes from India.

MAIN OUTCOME MEASURES

Identical laboratory procedures were used to determine nicotine content (in duplicate) and physical characteristics.

RESULTS

The nicotine concentration in the tobacco of bidi cigarettes (21.2 mg/g) was significantly greater than the tobacco from the commercial filtered (16.3 mg/g) and unfiltered cigarettes (13.5 mg/g).

CONCLUSIONS

Bidi cigarettes contain higher concentrations of nicotine than conventional cigarettes. Therefore, it is logical to presume that bidi smokers are at risk of becoming nicotine dependent. These findings belief a popular belief among US teens that bidis are a safe alternative to commercial cigarettes.

Exon scanning of the entire TSC2 gene for germline mutations in 40 unrelated patients with tuberous sclerosis

Tuberous sclerosis complex (TSC) is a dominantly inherited multisystem disorder resulting in the development of hamartomatous growths in many organs. Genetic heterogeneity has been demonstrated linking the familial cases to either TSC1 at 9q34.3, or TSC2 at 16p13.3. About two-thirds of the TSC cases are sporadic and appear to represent new mutations. While both genes are thought to account for all familial cases, with each representing approximately 50% of the mutations, the proportion of sporadic cases with mutations in TSC1 and TSC2 is yet to be determined. We have examined the entire coding sequence of the TSC2 gene in 20 familial and 20 sporadic cases and identified a total of twenty-one mutations representing 50% and 55% of familial and sporadic cases respectively. Our rate of mutation detection is significantly higher than other published reports. Twenty out of 21 mutations are novel and include 6 missense, 6 nonsense, 5 frameshifts, 2 splice alterations, a 34 bp deletion resulting in abnormal splicing, and an 18 bp deletion which maintains the reading frame. The mutations are distributed throughout the coding sequence with no specific hot spots. There is no apparent correlation between mutation type and clinical severity of the disease. Our results document that at least 50% of sporadic cases arise from mutations in the TSC2 gene. The location of the mutations described here, particularly the missense events, should be valuable for further functional analysis of this tumor suppressor protein.

Analysis of both TSC1 and TSC2 for germline mutations in 126 unrelated patients with tuberous sclerosis

Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by the development of multiple hamartomas involving many organs. About two-thirds of the cases are sporadic and appear to represent new mutations. With the cloning of two causative genes, TSC1 and TSC2 it is now possible to analyze both genes in TSC patients and identify germline mutations. Here we report the mutational analysis of the entire coding region of both TSC1 and TSC2 genes in 126 unrelated TSC patients, including 40 familial and 86 sporadic cases, by single-stranded conformational polymorphism (SSCP) analysis followed by direct sequencing. Mutations were identified in a total of 74 (59%) cases, including 16 TSC1 mutations (5 sporadic and 11 familial cases) and 58 TSC2 mutations (42 sporadic and 16 familial cases). Overall, significantly more TSC2 mutations were found in our population, with a relatively equal distribution of mutations between TSC1 and TSC2 among the familial cases, but a marked underrepresentation of TSC1 mutations among the sporadic cases (P = 0.0035, Fisher's exact test). All TSC1 mutations were predicted to be protein truncating. However, in TSC2 13 missense mutations were found, five clustering in the GAP-related domain and three others occurring in exon 16. Upon comparison of clinical manifestations, including the incidence of intellectual disability, we could not find any observable differences between TSC1 and TSC2 patients. Our data help define the distribution and spectrum of mutations associated with the TSC loci and will be useful for both understanding the function of these genes as well as genetic counseling in patients with the disease.

The development of hip osteoarthritis: implications for conservative management

Hip osteoarthritis (OA) can be the result of a multitude of causes. There is some evidence to suggest that a dysfunction in the neuromuscular system may contribute to the development of hip OA. This article reviews the forces and loads at the hip joint and the different presentations of hip OA in order to present a hypothesis that the neuromuscular system can play a role in the development of hip OA. Changes in the neuromuscular system include alterations in gait patterns and changes in muscular synergies. An improved understanding of the role these factors may play in the development of hip OA provides a perspective to explore treatment rationales and to provide more effective conservative management.

Modelling the training effects of kinaesthetic acuity measurement in children

In previous papers (Sims, Henderson, Hulme, & Morton, 1996a; Sims, Henderson, Morton, & Hulme, 1996b) we have found that the motor skills of clumsy children are capable of significant improvement following relatively brief interventions. Most remarkably, this included a 10-minute intervention while testing the kinaesthetic acuity of the children using a staircase method (Pest). In this paper, we show that Pest testing improves the kinaesthetic acuity of normal children as well. We analyse the available data on the development and improvement of motor skills and kinaesthetic acuity and derive a causal model for the underlying skills. We show that at least three independent cognitive/biological components are required to account for the data. These three components are affected differently by the various interventions that have been tried. We deduce that improvement on a general test of motor impairment can be found as a result of training in kinaesthetic acuity or through other, independent factors.

Are MAO-A deficiency states in the general population and in putative high-risk populations highly uncommon?

Lack of monoamine oxidase A (MAO-A) due to either Xp chromosomal deletions or alterations in the coding sequence of the gene for this enzyme are associated with marked changes in monoamine metabolism and appear to be associated with variable cognitive deficits and behavioral changes in humans and in transgenic mice. In mice, some of the most marked behavioral changes are ameliorated by pharmacologically-induced reductions in serotonin synthesis during early development, raising the question of possible therapeutic interventions in humans with MAO deficiency states. At the present time, only one multi-generational family and a few other individuals with marked MAO-A deficiency states have been identified and studied in detail. Although MAO deficiency states associated with Xp chromosomal deletions were identified by distinct symptoms (including blindness in infancy) produced by the contiguous Norrie disease gene, the primarily behavioral phenotype of individuals with the MAO mutation is less obvious. This paper reports a sequential research design and preliminary results from screening several hundred volunteers in the general population and from putative high-risk groups for possible MAO deficiency states. These preliminary results suggest that marked MAO deficiency states are very rare.

Linguistic dissociations in Williams syndrome: evaluating receptive syntax in on-line and off-line tasks

Williams syndrome (WS) is a neurodevelopmental disorder of genetic origin which results in relatively spared language in the face of serious non-verbal deficits. There is controversy, however, about how intact WS language abilities are. The discussion has focused on impairments of lexico-semantics and of morphological feature analysis, with the presumption that WS syntax is intact. We challenged this view and assessed WS receptive syntax by using two tasks testing various syntactic structures: an on-line word monitoring task and an off-line picture-pointing task. WS performance on the off-line task was generally poor. By contrast, their performance on the on-line task was far better and allowed us to ascertain precisely which aspects of WS receptive syntax are preserved and which are impaired. WS participants were sensitive to the violation of auxiliary markers and phrase structure rules but, unlike both the normal young and elderly controls, they did not show sensitivity to violations of subcategory constraints. The present study suggests that there exist dissociations within WS language which are not restricted to lexico-semantics or to morphological feature analysis, but which also invade their processing of certain syntactic structures. We conclude by arguing that WS syntax is not intact and that their language might turn out to be more like second language learning than normal acquisition.

ZOO-FISH of a microdissection DNA library and G-banding patterns reveal the homeology between the Brazilian rodents Akodon cursor and A. montensis

The neotropical rodents Akodon cursor (2n = 14, 15, and 16) and A. montensis (2n = 24 and 25), two closely related and morphologically indistinguishable species, have been compared by G-banding and chromosome painting. In situ hybridization of a biotinylated DOP-PCR product obtained from a microdissected chromosome of A. cursor onto A. montensis chromosomes was performed in combination with localization of telomeric sequences using a (TTAGGG)n oligomer as a FISH probe. The results provide evidence of the complex chromosomal rearrangements suggested by GTG-banding analysis, indicating the origin of one A. cursor autosome from three different A. montensis autosomes. Furthermore, the complete cytogenetic homeology between the A. cursor and A. montensis karyotypes was determined, along with the occurrence of tandem fusions and pericentric inversions and the loss of telomeres, centromeres, and chromosome arms. Evidence for the ancestral origin of the A. cursor karyotype is also provided.

The remediation of clumsiness. I: An evaluation of Laszlo's kinaesthetic approach

The effectiveness of a kinaesthetic training programme proposed by Laszlo for children with movement difficulties was evaluated by comparing two groups of 10 'clumsy' children matched pairwise on age, IQ and sex as well as degree of kinaesthetic and motor impairment. Tests of kinaesthetic ability, using the Parameter Estimation by Sequential Testing (PEST) procedure, and motor competence administered before and after treatment revealed an improvement in both groups on all measures but no differential effect of the training programme. Immediately after training, the changes we obtained in motor performance were confined to balance skills but, at follow up, 3 months later, changes in manual and ball skills were also evident. This unusual pattern of change requires replication. Our findings forced us to consider the possibility that any effect of Laszlo's recommended training programme had been obscured by our use of the PEST procedure, which had in itself facilitated motor learning.

The remediation of clumsiness. II. Is kinaesthesis the answer?

The paper reports the second of two studies designed to evaluate the effectiveness of the Kinaesthetic Training Programme (Laszlo and Bairstow, 1985) for children with movement difficulties. Three groups of 12 children were matched on age, IQ and sex as well as degree of kinaesthetic and motor impairment. One group received the Laszlo training, another received a training programme designed to avoid explicit reference to kinaesthesis and the third group received no training. Children receiving no intervention failed to show a change in performance. By contrast, the motor competence of both groups of treated children improved significantly. There was no advantage for the Laszlo trained group. It seems that in designing a remediation programme for clumsy children, the way that training is presented is as important as its actual content.

Rethinking metalinguistic awareness: representing and accessing knowledge about what counts as a word

Developmentalists have argued that young children have a confused notion of the metalinguistic concept word and that they cannot focus on single word boundaries when words occur in normal syntactic/semantic frames. We challenge these assumptions and present a new technique which engages normal syntactic-semantic processing but which, once it is interrupted on-line, introduces a metalinguistic component. In three experiments, children listened to a story in which the narrator paused on open or closed class words and then asked children to repeat "the last word" or "the last thing" that she had said each time she stopped. The results show that children as young as 4 1/2-5 years treat both open and closed categories as words and clearly differentiate word and thing. We conclude by suggesting that the new technique may be useful for enhancing early reading readiness and for reassessing the relationship between literacy and metalinguistic awareness.

Neuroradiologic findings in fucosidosis, a rare lysosomal storage disease

Fucosidosis is a rare lysosomal storage disorder with the clinical features of mental retardation, cardiomegaly, dysostosis multiplex, progressive neurologic deterioration, and early death. The neuroradiologic findings in two patients are reported, and include abnormalities within the globus pallidus (both patients) and periventricular white matter (one patient).

Detection of Rochalimaea henselae DNA in specimens from cat scratch disease patients by PCR

A PCR assay was developed by using degenerate primers that allow amplification of a 414-bp fragment of DNA from the rickettsia-like organisms Rochalimaea henselae and R. quintana. Internal oligonucleotides were used as hybridization probes, permitting rapid differentiation of these two Rochalimaea species. DNAs from 12 different isolates of R. henselae were amplified with the PCR primers, and the resulting 414-bp PCR product hybridized only with the R. henselae-specific probe. DNAs from four different isolates of R. quintana were amplified and produced a PCR product of the same size that hybridized only with the R. quintana-specific probe. DNAs from isolates of R. elizabethae, R. vinsonii, Bartonella bacilliformis, and Afipia felis failed to amplify the 414-bp fragment in the PCR assay. This two-step assay was applied to DNAs extracted from 16 fresh (unfixed) lymph node biopsy specimens and nine aspirates from patients with clinical cat scratch disease (CSD) to assay for the presence of R. henselae or R. quintana DNA in these samples. Twenty-one (84%) of 25 lymph node samples from CSD patients were positive for R. henselae, while none were positive for R. quintana. The characteristic 414-bp fragment was not amplified from eight lymph node tissue samples from non-CSD cases. These results provide evidence that R. henselae, and not R. quintana, plays the central role in the etiology of CSD.

A mutation in the Norrie disease gene (NDP) associated with X-linked familial exudative vitreoretinopathy

Familial exudative vitreoretinopathy (FEVR) is a hereditary disorder characterized by an abnormality of the peripheral retina. Both autosomal dominant (adFEVR) and X-linked (XLFEVR) forms have been described, but the biochemical defect(s) underlying the symptoms are unknown. Molecular analysis of the Norrie gene locus (NDP) in a four generation FEVR family (shown previously to exhibit linkage to the X-chromosome markers DXS228 and MAOA (Xp11.4-p11.3)) reveals a missense mutation in the highly conserved region of the NDP gene, which caused a neutral amino acid substitution (Leu124Phe), was detected in all of the affected males, but not in the unaffected family members, nor in normal controls. The observations suggest that phenotypes of both XLFEVR and Norrie disease can result from mutations in the same gene.

A nurse-managed multiple sclerosis clinic: improved quality of life for persons with MS

Multiple sclerosis (MS) is a complex disease, the symptoms of which may wax and wane on a daily basis. Conventional treatment for MS patients may involve numerous trips to a variety of clinics, physicians, and rehabilitation settings. This article describes a nurse-managed MS clinic which employs an interdisciplinary and holistic approach to treatment of MS patients with the goal of improving their quality of life and coordinating their health care. In this article, the services of the clinic are described, emphasizing the roles of the nurse practitioner (clinic manager), rehabilitation nurse specialist, and nursing director of the hospital-based home care program. A case study example of the interdisciplinary nature of this clinic's program with one MS patient is included.

Glutamate recognition sites in human fetal brain

We used in vitro autoradiography with [3H]glutamate to examine the distribution of glutamate recognition sites in 18 and 21 week gestation human fetal brains. We found a wide distribution of [3H]glutamate binding in both specimens, in a pattern distinct from that reported in adult brain using the same autoradiographic methods. In fetal brain, prominent [3H]glutamate binding was evident in hippocampal formation, caudate-putamen, globus pallidus, subthalamic nucleus, reticular nucleus of thalamus and substantia innominata.

On the receiving end--II. Linear analogue self-assessment (LASA) in evaluation of aspects of the quality of life of cancer patients receiving therapy

Linear analogue self-assessment (LASA) scales were used to measure general well-being and specific factors (mood, pain, nausea and vomiting, appetite, breathlessness, physical activity) in patients receiving therapy for malignant melanoma, small cell bronchogenic carcinoma (SCBC) or ovarian cancer. Among the patients with SCBC and melanoma, high correlations were observed between LASA scores for general well-being, mood and appetite. There was a significant relationship between performance status and LASA scores for general well-being, pain and appetite. Among patients with ovarian cancer, there was a significant association between performance status and LASA scores for general well-being, breathlessness and physical activity. Objective response category was related to change in LASA scores for pain. Changes in LASA scores during treatment reflected increased morbidity during radiotherapy in patients also receiving chemotherapy for SCBC. The LASA technique provides a convenient method for the assessment of quality of life in patients receiving cancer therapy, and potentially allows comparison of patient perception of treatment-related morbidities.

Lorazepam as an adjunct to antiemetic therapy with haloperidol in patients receiving cytotoxic chemotherapy

Twenty-seven consecutive patients were treated with 3 mg oral lorazepam and 2.5 mg intravenous haloperidol in an effort to improve patient tolerance of cytotoxic chemotherapy and decrease nausea and vomiting. Antiemetic efficacy and side-effects were assessed using a patient questionnaire. Vomiting either did not occur, or was considered to be of only moderate intensity in 22 patients (81%) and usually ceased within 24 hours of commencing chemotherapy. Similarly, nausea was either absent or of only moderate severity, lasting less than 48 hours in the majority of patients. Eight of 11 patients who had received similar previous cytotoxic treatment with antiemetic agents but not lorazepam considered that lorazepam and haloperidol had considerably improved their tolerance of chemotherapy. The side-effects of haloperidol and lorazepam were mild and well tolerated.

Single-agent versus combination antiemetic treatments in patients receiving cytotoxic chemotherapy

We report the results of two clinical trials in which patients receiving either doxorubicin (Adriamycin)/cyclophosphamide or cis-platinum cytotoxic chemotherapy were assigned at random either a single or a combination antiemetic treatment. The aim of each trial was to assess whether combination antiemetic therapy would result in improved efficacy. Sixty patients commencing doxorubicin/cyclophosphamide therapy were divided in two random groups to receive either haloperidol or haloperidol plus amitriptyline, and 80 patients commencing cis-platinum therapy were divided at random to receive either metoclopramide or metoclopramide plus promethazine. No statistically significant differences were apparent between single and combination antiemetic regimens in either of the two treatment groups. Antiemetic agents were generally well-tolerated, but minor side effects were common. The failure of our combination antiemetic regimens to intensify the proven antiemetic efficacy of single agents emphasises the need for re-evaluation of currently used antiemetic agents and their dosage schedules.

Characterization of an inhibitory receptor in rat hippocampus: a microiontophoretic study using conformationally restricted amino acid analogues

1 Pyramidal cells in rat hippocampus were used to study the molecular dimensions of a receptor for inhibitory amino acids in the central nervous system. The inhibitory potencies of gamma-aminobutyrate (GABA), beta-alanine and glycine were compared by standard microiontophoretic techniques. Subsequently, rigid cyclopentane and cyclohexane amino acid analogues were applied by iontophoresis and their relative efficacies were compared with those of the naturally occurring amino acids.2 GABA was the most effective of the small aliphatic amino acids in producing inhibition of the firing of hippocampal pyramidal neurones. beta-Alanine was less effective and glycine was the least effective. GABA-induced inhibition was antagonized by concurrent iontophoresis of picrotoxin or bicuculline, whereas strychnine did not antagonize GABA inhibition.3 The ability of the series of substituted aminocyclopentane and aminocyclohexane carboxylic acids to produce inhibition of pyramidal cells was a direct function of the separation of amino and carboxylic acid groups. In both series of the cyclic amino acids the most potent inhibition was demonstrated when the spatial separation was similar to that of the extended GABA molecule (4.74 A). Additionally, the inhibition of hippocampal pyramidal cells by (+/--cis-3-amino-cyclopentanecarboxylic acid, like that produced by GABA, could be blocked by simultaneous application of picrotoxin or bicuculline, but not by strychnine.4 The present results suggest that the physiologically active conformation of GABA is the fully extended molecule, and additionally indicate that one dimension of the postsynaptic receptor site is within the range of 4.2 to 4.8 ångströms.